NCC222569_FRO Submitted_20220725

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Mallory Creek - Phase 1
1. Project Name
2. Location of land -disturbing activity: County Brunswick _ City or Township Leland
Highway/Street Mallory Creek Drive Latitude34.188287 Longitude-78.014262
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 89.50
6. Amount of fee enclosed: $ 9,000 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jamison Fair E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mallory Creek Land & Timber Inc
Name Telephone Fax Number
PO Box 3649 Mallory Creek Drive
Current Mailing Address Current Street Address
Wilmington NC 28406 Leland NC 28479
City State Zip City State Zip
10. Deed Book No. 01 192 Page No. 0764 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pulte Home Company, LLC [e-mail]
Name E-mail Address
4136 Passerine Ave
Current Mailing Address Current Street Address
Wilmington NC 28416
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Parry is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Chris Raughley [e-mail]
Name of Registered Agent
1225 Crescent Green Drive, Suite 250
Current Mailing Address
Cary, North Carolina 27518
City
State
Telephone [phone]
Zip
E-mail Address
Current Street Address
City State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Chris Raughley
Type or print name
CA,,.,, ,, R our r x
Signature
VP of Land
Title or Authority
3 - VS'- 22
Date
1. PA-P i (A m.24--AKA a Notary Public of the County of VIOY--e_
State of North Carolina, hereby certify that CM +)► f Q'OW01�j ( _eAj appeared
personally before me this day and being duly sworn acknowledged' that the above form was
executed by him.
Witness my hand and notarial seal, this 2'5-
day of M w►. r 20 22
Seal
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Notary
My commission expires >-I I2-IIL<-